Wedgewood Healthcare Center

Based on observation, record review and interview, the facility failed to ensure smoking materials were secured in a locked area when not in use for 5 of 25 smokers reviewed for accidents hazards. (Residents 6, 46, 54, 72, and 86) Findings include: 1. During an observation on 8/9/24 at 10:00 a.m., Resident 6 had her cigarettes and lighter laying on the bedside table. The resident was sound asleep sitting up in her wheelchair. During am observation on 8/9/24 at 1:00 p.m., Resident 6 had her cigarettes and lighter laying on her bedside table. She had just finished eating her lunch. During an interview on 8/11/24 at 12:55 p.m., Resident 6 indicated she did not lock up her lighter. She indicated the staff trust me with my lighter When she left her room, she would hide her lighter and cigarettes underneath her left leg where no one could see them. During an observation on 8/12/24 at 8:30 a.m., Resident 6 had her cigarette lighter laying on her bedside table. 2. During an interview on 8/9/24 at 1:00 p.m., Resident 54 indicated she had her cigarettes and lighter in her purse. She would…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a dialysis access site was monitored and the physician was notified for 1 of 2 resident reviewed for dialysis. (Resident 51) Findings Include: The record for Resident 51 was reviewed on 8/8/24 at 10:56 a.m. The diagnoses included, but were not limited to, peripheral vascular angioplasty with implants and grafts, anemia in chronic kidney disease, hypo-osmolality and hyponatremia, chronic kidney disease, diabetes, and acute kidney failure.c The physician orders, dated 4/15/24,indicated staff were to monitor the dialysis site for signs and symptoms of infection, monitor the graft site for signs and symptoms of infection, and monitor for thrill and bruit every shift. The physician's order, dated 4/25/24, indicated the resident was to receive hemodialysis every Tuesday, Thursday, and Saturday. The Annual MDS (Minimum Data Set) assessment, dated 5/10/24, indicated the resident was cognitively intact. , The care plan, initiated on 4/16/24 and revised on 8/7/24 indicated, Resident 51 was currently on dialysis therapy. He…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure infection control practices were followed for proper procedures during 2 of 2 observations of incontinence care related to infection control. (Resident 196) Findings include: 1. The record for Resident 196 was reviewed on 8/7/24 at 11:00 a.m. The resident's diagnoses included, but were not limited to, encephalopathy, acute kidney failure, dementia, anxiety disorder, intellectual disabilities, muscle weakness, abnormalities of gait and mobility, lack of coordination, and cognitive communication deficit. The admission MDS (Minimum Data Set) assessment, dated 7/26/24, indicated the resident was severely cognitively impaired. He was frequently incontinent of bowel and bladder. The care plan, dated 8/1/24, indicated the resident was incontinent of bowel and bladder due to impaired cognition and impaired mobility. The interventions, dated 8/1/24, indicated for staff to apply barrier creams as needed, check the resident for incontinence., wash, rinse, and dry the perineum. During an observation of wound care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow medication administration parameters (Residents B, D and H); obtain blood pressure as ordered for 7 days (Resident F); and complete non-pressure wound treatments as ordered (Residents B and D) for 4 of 6 residents reviewed for quality of care. Findings include: 1.a. The clinical record for Resident B was reviewed on 7/24/24 at 1:35 p.m. The resident's diagnoses included, but were not limited to, diabetes, hypertension, and morbid obesity. The care plan, dated 10/27/23, indicated the resident had hypertension (high blood pressure) and staff were to administer the resident's medications as ordered by the medical provider. The physician's order, dated 11/21/23, indicated the resident was to receive Carvedilol 12.5 mg (milligrams) twice daily at 8:00 a.m. and 8:00 p.m. for hypertension. Staff were to hold the resident's medication for a SBP (systolic blood pressure) less than 110 or a pulse less than 60. The resident's May and June 2024 MAR (medication administration record) indicated the following: - On 5/06/24 at 8:00…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure Indwelling catheter care was completed for 1 of 1 residents reviewed for Indwelling catheters. (Resident E) Findings include: The clinical record for Resident E was reviewed on 7/24/24 at 3:03 p.m. The resident's diagnosis included, but was not limited to, sacral region pressure ulcer, stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle). The care plan, dated 2/15/23, indicated the resident required a condom catheter due to impaired skin integrity and staff were to provide catheter care every shift. The March 2024 treatment administration record (TAR) indicated staff were to cleanse the resident's condom catheter with soap and water every shift and to change the drainage bag weekly on Mondays. The resident's March 2024 TAR indicated the resident's condom catheter care was not completed on the following dates and shifts: - 3/01/24 - 3/02/24 on day shift - 3/04/24 on night shift - 3/05/24 on day shift - 3/07/24 on day shift - 3/10/24 on day shift - 3/11/24 on day and night shift - 3/13/24 on night…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure a staff member followed infection control practices for 1 of 5 observations related to infection control. ( CNA 4) Findings include: During an observation on 7/23/24 at 8:13 p.m., CNA (Certified Nursing Aide) 4 was observed to exit a resident's room wearing gloves and carrying a soiled brief in one gloved had and a soiled pair of pants in the other. During an interview on 7/26/24 at 12:34 p.m., CNA 5 indicated after resident care was provided, soiled briefs should be placed in a bag and soiled clothing in a separate bag. Soiled gloves should have been removed prior to exiting the resident's room and all soiled clothing should be in a bag. The bagged items should then be placed in the soiled utility room. On 7/25/24 at 1:48 p.m., the Regional Director of Clinical Operations provided a current copy of the document titled Infection Prevention Program effective 3/9/2000. It included, but was not limited to, Policy .It is the policy of this facility to provide resident centered care .Residents have the right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a resident that self-administered medications was appropriately assessed for self-administration for 1 of 3 residents reviewed for medications. (Resident E) Findings include: The clinical record for Resident E was reviewed on 3/20/24 at 1:30 p.m. The resident's diagnoses included, but were not limited to, osteoarthritis, morbid obesity, congestive heart failure, chronic respiratory failure with hypoxia, depression, and hypertension. Review of the March 2024 physician's orders indicated the resident was to receive the following medications every morning: -Aspirin 81 mg (milligrams) chewable for heart health -Carvedilol 3.125 mg twice daily for hypertension -Clopidogrel Bisulfate 75 mg daily for heart health -Ergocalciferol 1.25 mg daily for supplement -Gabapentin 100 mg twice daily for health maintenance -Lexapro 10 mg daily for depression On 3/20/24 at 11:40 a.m., Resident E was observed resting in bed in her room. On the resident's bedside table was a medication cup with 6 unidentified medications.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a resident's (Resident B) representative was provided a bed hold notification information, in a timely manner, for 1 of 3 residents reviewed for transfer/discharge. Findings include: The clinical record for Resident B was reviewed on 9/15/23 at 10:25 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, adjustment disorder, post traumatic stress disorder, schizoaffective disorder and bipolar disorder. The progress note, dated 8/16/23 at 9:16 a.m., indicated the resident was sent to a psychiatric hospital related to behaviors towards staff. Review of the bed hold authorization form indicated Resident B's representative was not informed related to the bed hold policy until 9/6/23 which was three weeks after his discharge to the hospital. During an interview on 9/15/23 at 10:51 a.m., the complainant indicated she was notified of the bed hold authorization on 9/6/23. During an interview on 9/15/23 at 12:41 p.m., the Admissions Coordinator indicated the bed hold authorization got missed. On 9/15/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to promptly resolve the grievances and recommendations made by the Resident Council during 9 of 12 meetings and 7 of 11 complaint logs reviewed where the same issues were being reported as continuing problems. This deficient practice had the potential to affect all 106 residents residing in the facility. Findings include: On 6/19/23 at 2:00 p.m., the Resident Council minutes for the months of July 2022 through June 2023 were reviewed after permission was obtained by the Resident Council President. The review of the Resident Council minutes indicated on 7/26/22 the residents' had the following concerns: - Staff were not distributing trays in a timely manner. - Staff were not reminding people on their shower days and/or putting them off until too late. - Staff were not offering to change bed linens. No response to these concerns could be located. The review of the Resident Council minutes indicated on 11/22/22 the residents' had the following concerns: - Certified Nurse Aides (CNA) were rude when they answered call lights. -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure the oxygen concentrator filters were maintained for 9 of 20 residents reviewed for respiratory care. (Residents 18, 15, D, 99, 78, 66, 65, 6, and 40) Findings include: 1. During the initial tour on 6/14/23 at 9:32 a.m., Resident 18's oxygen concentrator filter was completely coated with a white powdery substance. The record for Resident 18 was reviewed on 6/21/23 at 3:12 p.m. The diagnoses included but were not limited to COPD (chronic obstructive pulmonary disease), chronic congestive heart failure, and automatic cardiac defibrillator. The admission MDS (Minimum Data Set) assessment, dated 5/19/23, indicated the resident was cognitively intact. The care plan, dated 5/17/23 and last revised on 6/15/23, indicated the resident had COPD with shortness of breath while lying flat. She required oxygen at 2 L related to her disease process. The interventions, dated 6/15/23, included, but was not limited to, provide oxygen therapy as ordered. Change tubing per facility policy. The physician's orders, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure the kitchen was maintained in a sanitary manner for 3 of 3 kitchen observations. This deficient practice had the potential to affect all 106 residents currently residing at the facility. Findings include: During the initial tour of the kitchen on 6/14/23 at 9:12 a.m., the following concerns were observed: - There was heavy black grime under the dishwasher, on the pipes and going up the walls. There were also two dirty cups and two forks on the floor under the dishwasher. - There was grime under the floor beneath the deep fryer and the steam and hold oven. - There was heavy grease build up to the wall and floor behind and under the deep-fryer and oven as well as on the sides of the grill. - There was a broken white dish and copious amounts of food debris under the stove and deep fryer, including several French fries, tater tots, and scraps of aluminum foil. - There was a heavy black buildup of residue on the splatter guard of the stove. - There was a heavy accumulation of grease, approximately 1 half…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to notify the physician of a blood sugar levels over 400 mg/dL for 1 of 3 residents reviewed for Notification of Change. (Resident 79) Findings include: The record for Resident 79 was reviewed on 6/15/23 at 11:44 a.m. The diagnoses included, but were not limited to, type 2 Diabetes Mellitus, chronic kidney disease stage 3, and acute kidney failure. The Quarterly MDS (Minimum Data Set) assessment, dated 3/30/23, indicated the resident was cognitively intact. The care plan, dated 8/8/22 and last revised on 10/10/22, indicated the resident had Diabetes Mellitus and was non-compliant with diet, placing him at risk for complications related to high blood glucose. The interventions included, but were not limited to, administer insulin injections per orders and report any abnormal findings to the medical provider. The physician order, dated 1/19/23, indicated staff were to administer the resident's insulin lispro subcutaneously with meals by pen-injector as per sliding scale: If the resident's blood sugar was 151 to 200 they were to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure the heating and air units were in good working condition for a comfortable temperature for 2 of 106 resident residing in the facility. (Residents E and D) Finding include: During and observation on 6/14/23 at 9:55 p.m., the HVAC (heating, ventilation, and air conditioning) unit was set to the fan only setting, upon entrance into Residents E and D's room. The room was observed to feel warm. During an interview on 6/14/23 at 9:55 a.m., Resident E, indicated the air conditioning unit was not functioning properly. The fan only button was on and was blowing warm air. If the cool setting was on, it would only run for 10 minutes or so and then shut off. The E9 (error) lighted setting would appear in the temperature screen. The HVAC unit didn't work even though it was new. The Maintenance Director informed Resident E that he couldn't do anything about it. During an interview on 6/15/23 at 10:44 a.m., Resident E indicated the HVAC unit was out and had been this way for a few months. Her roommate got hot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a resident was free of verbal abuse for 1 of 3 residents reviewed for abuse. (Resident 58) Findings include: The record for Resident 58 was reviewed on 6/15/23 at 12:53 p.m. The diagnoses included, but were not limited to, aphasia following cerebral infarction, dysphasia following cerebral infarction, dementia. The care plan, dated 5/1/22, indicated the resident had a self-care performance deficit and required assistance of 2 staff members with toileting and 1 staff member with personal hygiene. The record for Resident 12 was reviewed on 6/20/23 at 9:24 a.m. The Quarterly MDS (Minimum Data Set) assessment, dated 5/9/23, indicated the resident was cognitively intact. The statement of Resident 12 (Resident 58's roommate), dated 5/25/23, indicated early that morning during care, two aides came in to provide care to his roommate, Resident 58. Resident 58 was resistive to care and the male aide CNA (Certified Nurse Aide) 16 said to the resident . We aren't putting up with your s* tonight, you're going to get changed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure pressure reducing boots were in place as ordered for 1 of 6 residents reviewed for Pressure Ulcers. (Resident 22) Findings include: The record for Resident 22 was reviewed on 6/19/23 at 8:58 a.m. The diagnoses included, but were not limited to, contracture of unspecified joint, left hip, and left knee, osteomyelitis of vertebra, sacral, and sacrococcygeal region, cerebral infarction affecting right dominant side, pressure ulcer of the hip, and contracture of multiple sites both upper and lower extremities. The physician's order, dated 10/28/22, indicated the resident was to wear heel boots to his bilateral feet while in bed every shift for prevention. The physician's order, dated 10/28/22, indicated staff were to encourage the resident to float heels while in bed as tolerated every shift for preventative measure. The care plan, initiated on 10/18/22, indicated the resident had impaired skin integrity and was admitted with stage 3 pressure wound to his left hip and was at risk for altered skin…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure fall interventions were in place for 1 of 4 residents reviewed for accidents. (Resident 22) Findings include: The clinical record for Resident 22 was reviewed on 6/19/23 at 8:58 a.m. The diagnoses included, but were not limited to, contracture of unspecified joint, left hip, and left knee, osteomyelitis of vertebra, sacral, and sacrococcygeal region, cerebral infarction affecting right dominant side, pressure ulcer of hip, and contracture of multiple sites both upper and lower extremities. The care plan, dated 10/18/22, indicated the resident was at risk for falls related to gait and balance problems, impaired cognition, incontinence, medication, weakness, hemiplegia, and schizophrenia. The interventions, initiated on 10/18/22, indicated staff were to place the resident's call bell within reach, remind the resident to call for assistance, and personal items within reach. The nurse's note, dated 1/28/23 at 3:43 p.m., indicated the resident fell out of bed. He was moving around a lot and trying to fall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure proper maintenance of a catheter and drainage system off the floor for 1 of 2 residents reviewed for bowel and bladder. (Resident 57) Findings include: The record for Resident 57 was reviewed on 6/16/23 at 8:16 a.m. The diagnoses included, but were not limited to, urinary tract infection, ESBL (Extended Spectrum Beta Lactamase) resistance, acute cystitis, obstructive uropathy, acute kidney failure, and benign prostatic hyperplasia with lower urinary tract symptoms. The nurse's note, dated 6/21/22 at 3:20 p.m., indicated the resident was on an antibiotic for ESBL of his urine. The nurse's note, dated 9/19/22 at 7:33 p.m., indicated the resident was sent to the hospital and returned three days later with a diagnosis of a UTI (urinary tract infection) and was on IV (intravenous) antibiotics. He had a urinary catheter in place draining clear yellow urine. The Nurse Practitioner's (NP) note, dated 10/21/22 at 1:24 p.m., indicated the resident presented with dysuria. It was described as aching and burning.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure Social Services followed up on a resident's psychosocial well-being and care planned the behavior after an allegation of sexual inappropriateness was made. This deficient practice affected 1 of 3 residents reviewed for Social Services. (Resident 99) Finding includes: The Reportable to State Incident, dated 4/27/23 at 3:01 a.m., indicated the resident alleged that a man came into her room and was sexually inappropriate with her. The resident was sent to the hospital for evaluation and an investigation was started. The Executive Director (ED), Director of Nursing (DON), the physician and the police were notified. No injury was observed. The type of preventative measures to be put into place after the resident returned to the facility were: care plans and interventions would be updated, and the resident's well-being will be followed. The Hospitalist's progress note, dated 4/28/23, indicated that during the conversation between the resident and the Hospitalist about the possible sexual assault, the resident indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure insulin flexpens were labeled for 1 of 3 medication carts reviewed. (500 Hall medication cart) Findings include: During an observation of the 500 Hall medication cart on 6/20/23 at 10:32 a.m., the label was missing from a Humalog flexpen, a glargine flexpen and a Lantus flexpen. Three labeled flexpens were out of their bags with instructions and the LPN (Licensed Practical Nurse) placed them back into the correct bags. LPN 13 indicated she was not sure who the insulin flexpens with the missing labels belonged to. She was also not sure how the residents labels came off. During an interview on 6/21/23 at 11:04 a.m., LPN 12 indicated there was a problem in April with the insulin pens not having labels, but nothing recently. Nursing should make sure there was a label on the insulin. During an interview on 6/21/23 at 1:39 p.m., the RDCO (Regional Director of Clinical Operations) indicated the nurses should monitor the medications for an expiration date. Insulin pens should be labeled and bagged. If the nurse obtained the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure a drainage culture was obtained as ordered for 1 of 3 residents reviewed for laboratory services. (Resident 57) Findings include: The record for Resident 57 was reviewed on 6/16/23 at 8:16 a.m. The diagnoses included, but were not limited to, urinary tract infection, ESBL (Extended Spectrum Beta Lactamase) resistance, acute cystitis, obstructive uropathy, acute kidney failure, and benign prostatic hyperplasia with lower urinary tract symptoms. The care plan, dated 6/1/22 and last revised on 2/7/23, indicated the resident had a history of infections related to ESBL in his urine. Interventions included, but were not limited to, report abnormal findings to the medical provider, and obtain and monitor laboratory and diagnostic studies as ordered. The NP (Nurse Practitioner) note, dated 6/12/23 at 1:00 a.m., indicated the resident had abnormal non-bloody drainage from his penis. A new order was written to obtain a culture of the drainage. The Medication Administration Note, dated 6/13/23 at 4:08 p.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure PPE (Personal Protective Equipment) was donned and doffed per CDC (Centers for Disease Control and Prevention) guidelines upon exit from isolation rooms during 3 of 4 observations on the 300 and 500 halls. (LPN 16, LPN 17, and CNA 15) Findings include: 1. Upon entrance to the facility on 6/14/23 at 9:00 a.m., the ED (Executive Director) indicated surgical masks had to be worn at all times and an N-95 mask and full PPE was required in two rooms due to Residents 71 and 74 testing positive for COVID-19 on 6/13/23. During an observation and interview on 6/14/23 at 12:10 p.m., Licensed Practical Nurse (LPN) 16, entered Resident 74's room donned in a gown, gloves, surgical mask, and face shield. She did not don an N-95 mask. Upon exiting the room, she removed her PPE and disposed of it in the trash can just inside the resident's room and went back to her medication cart. She failed to change her surgical mask or sanitize her hands before working on the computer on the cart. She indicated she forgot the N-95 mask. 2. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.